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Date run 6/21/01 3:35:59PM SANWOUIN COUNTY PUBLIC HEALTH SEES Report u: 5023 <br /> Roo by Facility Information as of 6/21/01 Page #. 1 <br /> Record Selection Criteria: Facility ID FA0004097 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0002947 New Owner ID <br /> Owner Name: MARK III ENGINEER CONTR GROUP <br /> Owner DBA: <br /> Owner Address: 5101 FLORIN-PERKINS RD <br /> SACRAMENTO, CA 95826 <br /> Home Phone: Not Specified <br /> Work/Business Phone: Not Specified <br /> Mailing Address: 5101 FLORIN-PERKINS RD <br /> SACRAMENTO, CA 95826 <br /> Care of: OK& B/GREG SHUBERT <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0004097 <br /> Facility Name: STONEBRIDGE INDUST PARK LOT 8 <br /> Location: 1050 E GRANT LINE RD <br /> TRACY, CA 95376 <br /> Phone: <br /> Mailing Address: 1376 INDUSTRIAL BLVD <br /> WEST SACRAMENTO, CA 95691 <br /> Care of: MARK III ENGINEERING <br /> Location Code: 03 -TRACY APN: 237-020-1415 <br /> BOS District: 005- BEDFORD, LYNN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0003757 New Account ID: <br /> Mail Invoices to: Mail Invoices to: Owner/Facility/Account <br /> Account Name: STONEBRIDGE INDUST PARK LOT 8 (Circle One) <br /> Account Balance as of 6/21/01: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? elate <br /> 2960-RWQCB CLEAN UP SITE PR0009246 EE0000684-MICHAEL INFURNA ive Y N A Ul D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed In accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRAIN R D: '$150.00= Amount Paid Date <br /> Payment Ty Check Number CreditCardNumber Received by <br /> REHS: Date /7 /A l Account out: Date Ob/ ,,?[ <br /> COMMENTS: <br /> \\PHS-EHSQL-NTV\PPS\Envisions\Client Access\ENVISION\REPO <br />